Despite our best efforts and incorporation of proactive approaches to prevent struggle, a few students will require more time and individualized mentoring in order to be successful in their PA school journey.  Work with these students can be very time intensive, but the fruit of that labor can be incredibly rewarding.  Students who get off to a rocky start in the didactic curriculum can become competent, empathetic clinicians with the right guidance.  It is important for each program to have a specific outlined approach to remediation, with definitive intervention points and outcome measures.  It is also equally important that, while the process is well defined, there remains enough flexibility and a recognition that it should not be a one-size fits all approach.  

While lack of content knowledge is usually the “symptom” resulting in remediation efforts, resisting the urge to make interventions focused solely on relearning of particular content is vital.  This can result in reinforcement of surface learning of material with the aim of simply passing a retest.  It is analogous to putting a Band-Aid on a gaping wound, serving as a means to a specific end, but not addressing the underlying problem that will continue to rear its head until ameliorated.  While we do need to ensure that students learn the content in which they were found to be deficient, our effort is much better served through fostering metacognitive skills that can be applied to future learning of any subject, rather than simply attempting to reteach specific content.  Let’s examine some strategies that can be employed with individual learners to help strengthen their understanding of the effectiveness of their study and equip them with the tools to make mid-course corrections to ensure successful outcomes.   

Reflective Practice. Effective use of reflection as the foundation of study is at the root of successful metacognitive practice.  Students must be able to accurately assess the effectiveness of their study efforts in order to recognize what they know and don’t know.  Once knowledge gaps are identified, reflection must also include the ability to discern whether or not their current approach to study is the correct one to allow for the amelioration of the identified deficits.  Remediation research has shown that when students struggle, they are ill-equipped to adapt their study strategy, and often end up simply applying the same ill-suited methodology with greater intensity, expecting a different outcome.  Faculty mentoring can play a key role in ending this cycle.  Exam and study material reviews can assist in these efforts. 

Exam Item Tagging/Feedback. Beginning remediation efforts with a review of the failed assessment is a reasonable place to start.  Here again, curbing the instinct to simply review with students the exact questions they missed is important.  The issue is not that particular question…the gap in knowledge specific to the topic of that question is the problem.  When exam reviews are approached this way, many students default to simply memorizing the answer to the specific question, and if asked about the same content in a different manner, will be unable to answer it correctly.  Using detailed item tagging in electronic exam platforms, or creating a title for each question including the disease state/topic and task area, such as “cardiomyopathy treatment”, when assembling an assessment can allow for more meaningful feedback.  Providing students with the titles of questions they missed creates a roadmap for future study and also allows for the beginning of pattern recognition with regard to areas of weakness.  These can be further identified through instructive test taking.

Individualized Instructive Test Taking. Provision of real-time feedback can elucidate the source of issues with test taking.  Having a student answer test items in front of you, explaining their process and thinking allows for in-the-moment correction of poor strategy and faulty logic.  Modeling for students how to extract salient information from vignettes, how to appreciate that changes in things such as vital signs, allergies or co-morbidities may make one answer choice more correct than another, or how to reason through distractors independently using objective data to make answer choices can have a profound impact.  Having a student make a causal attribution for each missed question, such as unfamiliar material, misread question, or changing of answers will allow for correction of maladaptive test taking and study approaches.  Finally, looking for the information needed to correctly answer a missed question within a student’s notes can help them recognize if they are incorporating the needed information into their preparation at an appropriate level.  

Review of Study Skills/Strategies. A general review of a student’s study process during remediation is helpful in many ways.  Start by having students show you how they arrive at their final study product from day one.  What does their preparation for lecture look like?  How do they take notes in class?  What do they do with those notes after class?  How many iterations of their material do they create?  Many struggling students are drowning in the process of learning and need assistance from faculty to help them create a more organized approach.  Reviewing the concept of pre-reading and preparing lecture notes before class can allow for students to engage in the lecture process more actively.  Review student notes taken during lecture and the study product resulting from those notes.  It is surprising how often that process entails rote transcription of what the lecturer said, which is often already on the slide, and then verbatim transcription from PowerPoint handouts into a student created study document.  Two passes at material that have involved no synthesis or thought about the content other than to transcribe it is not likely to result in meaningful learning.  Often students don’t realize this is what they are doing until it is pointed out to them.  Removing the need for them to frantically scribble every word said and instead modeling for students how they can engage in more active listening in lecture, making note taking about tying pieces together, and creating study materials that promote synthesis will yield better results.   Many students have never done anything but memorize transcribed notes and they are at a loss for what to try next.  Tools like a learning style inventory can help.  

Learning Styles Inventory. Because most PA students were successful in their undergraduate studies, they continue with the same study strategies when they arrive at PA school.  They quickly find those strategies are ineffective, but don’t know what else to try.  Some might find success adapting methods used by classmates, but helping students find strategies that are better suited to their unique learning styles using learning styles inventories such as the VARK inventory can provide clearer direction.  Talking through the options for different approaches to study opens the student’s eyes to methods they may have never considered.  Encourage students to make one small change at a time and then reflect on the success of that change before making another.  Soon, through trial and error, most will land on the best approach for how they learn.   

Psycho-social Influences. Finally, be sure to address the psycho-social influences on the need to remediate.  Unaddressed test anxiety or external stressors can play a large role in a student's performance.  Likewise, once they get stuck in the remediation cycle, this anxiety can intensify, resulting in continued failure.  The perceived social stigma of remediation from peers and faculty can also contribute to feelings of being seen as “less than” by others.  Each of these factors influence the student’s self-efficacy beliefs and can negatively affect the likelihood their remediation attempts are successful.  Referrals to counseling services, as well as creating a culture that destigmatizes remediation, can address these issues.  By focusing on the benefits of successful remediation with the entire cohort proactively, and for struggling students when the need arises, can flip the script about remediation and lessen the anxiety surrounding the process.  

Keeping the focus of our remediation efforts, whether proactive for the entire cohort or deficit-reactive for the individuals that struggle, on fostering metacognitive development results in greater sustained academic successes for students and creates more self-directed clinicians who embody the qualities needed for life-long learning.